Indocyanine Green–Guided Decision‐Making for Cervical Esophagogastric Anastomosis Using the Modified Collard Technique: Implementation and Temporal Stability in a Consecutive Cohort

BACKGROUND: Anastomotic leakage (AL) remains a major complication after cervical esophagogastric anastomosis. Although indocyanine green (ICG) fluorescence imaging has been used to assess gastric conduit perfusion, its role in structured intraoperative decision-making and the temporal stability of outcomes remain unclear. METHODS: This single-center retrospective study included 507 consecutive patients who underwent esophagectomy with cervical esophagogastric anastomosis using the modified Collard technique under a standardized ICG-guided protocol. Intraoperative ICG imaging was used to identify poorly perfused distal conduit segments for exclusion. Temporal trends were evaluated using moving average and cumulative sum (CUSUM) analyses. RESULTS: Anastomotic leakage occurred in 19 patients (3.75%), including clinically relevant leakage (grade ≥ III) in 13 (2.56%). Reoperation was required in one case, with no leakage-related mortality. ICG assessment prompted additional proximal resection in 49.9% of evaluable patients, reflecting frequent detection of marginal distal perfusion; however, final anastomoses were consistently constructed within adequately perfused zones. Temporal analyses, including CUSUM, demonstrated sustained performance below a stringent 5% target rate throughout the study period. CONCLUSIONS: A standardized ICG-guided intraoperative decision-making strategy for cervical esophagogastric anastomosis using the modified Collard technique was associated with a low (3.75%) and temporally stable anastomotic leakage rate. Rather than serving as a binary perfusion test, ICG imaging functioned as a practical rule-out tool to exclude clearly unsafe conduit segments. When embedded within a structured decision-making framework, this approach enabled consistent implementation and durable reconstructive quality in routine clinical practice.